• Ectopic Pregnancy
  • Endometriosis
  • Ovarian Cyst
  • Pelvic Inflammatory Disease
  • Placental Abruption

Ectopic Pregnancy

  • Background
    • Implantation of a fertilized ovum outside the uterusT The fallopian tube is the most common.
    • Occurs in about 2% of all pregnancies and accounts for 6% of all maternal deaths.
  • Signs/Symptoms
    • Vaginal bleeding, abdominal/pelvic pain, adnexal mass, amenorrhea
    • Rupture of ectopic pregnancy can cause hypotension, syncope, and peritonitis 
  • Diagnosis
    • Beta HCG > 1500, but no signs of intrauterine pregnancy on transvaginal ultrasound.
    • If beta-hCG levels rise, but do not double over the course of 48 hours, then it is likely an ectopic pregnancy.
  • Treatment
    • Resuscitate, give RhoGAM to Rh ( -) women, consult OB/GYN
    • Methotrexate (unless contraindicated). Surgery may be needed.
Video Credit: Armando Hasudungan

*Deep Dive: Ectopic Pregnancy (SAEM)


  • Background
    • Endometriosis is the presence of endometrial tissue implanted outside the uterus (pelvic cavity, uterine ligament, bowel, lungs, ovaries, etc.)
    • Most common site is the ovaries
  • Signs/Symptoms
    • “Three D’s” (dyspareunia, dyschezia, dysmenorrhea)
    • Often presents asymptomatically or with pelvic pain before/during menses
  • Diagnosis
    • Laparoscopy and biopsy required for definitive diagnosis 
  • Treatment
    • Analgesics (NSAIDS)
    • Hormone therapy (danazol, oral contraceptives, progestins, GnRH agonists, aromatase inhibitors)
Video Credit: JJ Medicine

*Deep Dive: Endometriosis (Merck Manual)

Ovarian Cyst

  • Background
    • Fluid-filled sac within the ovary. Generally benign, but can lead to torsion, rupture, hemorrhage, or infection.
    • Follicular cysts are the most common; other types include corpus luteum cysts (can cause rapid bleeding) and Theca lutein cysts (seen in pregnancy) 
  • Signs/Symptoms
    • Most are asymptomatic; common symptoms include lower abdominal pain, bloating, and dyspareunia.
    • If ruptured, can cause significant pain, hypotension, tachycardia
  • Diagnosis
    • Transvaginal ultrasound
    • Masses > 5 cm concerning for ovarian torsion
  • Treatment
    • Most cysts < 5cm resolve on their own. Provide NSAIDs for analgesia
    • Surgery required for complicated cysts
Video Credit: Dr. Paul Bolin

*Deep Dive: Benign Ovarian Masses (Merck Manual)

Pelvic Inflammatory Disease

  • Background
    • Acute, bacterial infection that ascends from cervix/vagina to the upper genital tract (uterus, fallopian tubes, ovaries, and adjacent structures)
    • Most commonly caused by Chlamydia trachomatis
  • Signs/Symptoms
    • Lower abdominal pain, fever, vaginal discharge/bleeding
    • (+) “Chandelier sign” (cervical motion tenderness), (+) mucopurulent cervicitis
  • Diagnosis
    • Clinical diagnosis
    • Must have tenderness (abdominal, uterine, adnexal, or cervical) + one more criteria (fever, discharge, elevated ESR/CRP, documented GC/Chlamydia infection)
  • Treatment
    • Antibiotics (ex. ceftriaxone + doxycycline +/- metronidazole)
    • Treat infected partners
Video Credit: Osmosis

*Deep Dive: Pelvic Inflammatory Disease (WikEM)

Placental Abruption

  • Background
    • Hemorrhage caused by premature separation (partial or full) of implanted placenta from the uterine wall after 20 weeks gestation.
    • Often associated with trauma; most common cause of third trimester bleeding
  • Signs/Symptoms
    • Painful vaginal bleeding is the most common sign, but may not always be present. 
    • May have tender uterus and signs of shock
  • Diagnosis
    • Clinical diagnosis
    • Ultrasound may help identify retroplacental bleeding
  • Treatment
    • Stabilize (ABC’s, blood products, RhoGAM). Consult OB/GYN emergently
    • Definitive treatment is delivery of the fetus/placenta. 
Video Credit: Osmosis

*Deep Dive: Placental Abruption (emDOCs)

Brandon Simpson, PA-C
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